New discharge planning standards are issued
Psychiatric hospitals may be ahead of the curve
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in August issued new guidelines for discharge planning, which become effective Jan. 1, 2001.
Essentially, the standards require early planning for patient discharge and that the patient and family be informed from the outset regarding the need for transfer to another health care setting.
"The way we came to the new standards was based on feedback, particularly from the National Association for the Mentally Ill [NAMI]," says Mary Cesare-Murphy, PhD, executive director for Behavioral Health Accreditation at the Joint Commission.
The new standards are based on the successful discharge planning techniques used in psychiatric hospitals, according to Cesare-Murphy. Once JCAHO had NAMI’s feedback regarding discharge planning, "we did a cross-walk," she says. "We compared the standards for behavioral health with other hospital standards. We did feel there were two points not being addressed by hospitals as fully as they should have been: the need for planning early in the course of care and the right of patients and families to be fully informed early in the planning process."
Indeed, psychiatric hospitals may have been ahead of the curve in discharge planning. A survey by the Psychiatric Patient Advocate Office (PPAO) was commissioned in Canada last year to determine the adequacy of the discharge planning process in psychiatric hospitals there. The PPAO found that 62% of patients interviewed indicated they had been involved in planning their discharge. Furthermore, 62% of patients said they were involved in choosing their own housing. Also, 67% of patients said they knew who would be providing follow-up services to them, and 53% to 55% reported that treatment and financial and transportation arrangements were completed.
The study also found that the staff’s familiarity with the hospital discharge policies and procedures was an important first step in the discharge planning process. Those are the kind of results that JCAHO says it would like to see in all hospitals in the United States.
The new discharge planning assessment standards state that "the discharge planning is initiated early in the treatment process, based on requirements of the plan of care or other written guidelines. Criteria for discharge or terminating treatment are stipulated and may vary based on age and disability considerations and treatment objectives."
The standards for continuum of care stipulate that "the patient is informed in a timely manner of the need for planning for discharge or transfer to another organization or level of care." But what is the definition of "timely"?
Getting off to an early, well-documented start hasn’t always been easy. Nursing shortages have left some units without nurses consistently available to initiate and carry through on the planning process. "From a nurse’s standpoint, discharge planning has always started early," says Kelly McDevitt, RN, MS, ONC, orthopedic clinical case manager at University Hospital in Denver. "What has become a problem is the shortage of nurses on a unit to handle the planning from start to finish. It’s led to hospitals hiring more discharge planners and care coordinators to help with that end of the process. And we do make every effort to begin planning as soon as the patient is admitted."
Keeping the family informed
The new standards also say that the organization is responsible for keeping the patient and the patient’s family informed of the care process, especially when the organization anticipates some level of care continuing after discharge. "These discussions begin as early as possible in the care process, continue throughout it, and include the anticipated time of discharge. Patient and family education and continuity of care are related functions," according to the standard.
But early family involvement often poses problems. "Families are not as centrally located as they used to be," McDevitt explains. "By the time family members arrange a schedule to fly in from Cleveland or Seattle or wherever, several days may have gone by. Then when they arrive and we tell them [the patient] needs nursing home care, they need more time to investigate the care facilities available. It’s often not possible to involve the family early, and we can’t just take it upon ourselves to discharge a patient to facility A, B, or C. By the time the family arrives, looks at the choices, and makes an informed decision, we may be fairly well along in the planning process. And holding onto the patient drives our costs up in the bargain."
The standards go on to say that patient and family education should include information regarding:
- the conditions that may result in transfer to another organization or level of care;
- alternatives to transfer, if any;
- the clinical basis for discharge;
- the anticipated need for continued care following discharge.
But even in Canada, discharge planners face frustration much like their U.S. colleagues. There may be a disposition order requiring 24-hour supervision for a patient in a community setting. Or there may be conflict between a family member and a caregiver over just what is in the patient’s best interests. Or staff may work with team members who have differing views over what will best meet the patient’s needs after discharge.
Assisted living is sometimes considered the answer, especially with elderly patients who are not able to go back to their total independence. Although it offers a handy alternative to the nursing home, alternative living is not a panacea. For one thing it’s only available to those who can afford it. Since assisted living facilities do not accept Medicare funds, the door is closed to many less affluent patients. And many such facilities have waiting lists for admission.
There is also no regulation of assistant living facilities, which could lead to problems with patients who have specific medical needs or complicated post-discharge requirements.
"Basically, the hospital is responsible for keeping the patient and family informed and anticipating the need for change," says Cesare-Murphy.
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